Saturday, May 9, 2009

AMA letter backs Obama's broad principles for health system reform

The Association outlines the next steps Congress and the White House should take to turn the tenets into policy changes.

By Chris Silva, AMNews staff. Posted April 27, 2009.

The American Medical Association earlier this month further fleshed out what it will push for in this year's landmark health system reform debate, aligning itself with several core principles from President Obama and offering more specifics about how to achieve them.

In an April 13 letter to the White House, the AMA announced its strong support for eight guiding principles against which Obama has said he will gauge the health reform effort as he works with Congress. The AMA made the statement in an effort to show it is backing this "historic opportunity to improve the system," while also highlighting more specific issues the organization wants Congress to address this year, said AMA President Nancy H. Nielsen, MD, PhD. She co-signed the letter with AMA President-elect J. James Rohack, MD.

"We are committed to reform, and we want to expand access to care for all Americans," Dr. Nielsen said. "This is an important year, because more people may lose their jobs and their health insurance, and we have grave concerns about that and the loss of preventive services."

The eight basic principles -- including guaranteeing patient choice and aiming for universal health care coverage -- lack details, although Obama further outlined his long-term vision in his budget proposal released Feb. 26. The AMA letter indicates that the standards dovetail with more expansive policy changes for which the Association already is pushing.

But embracing the eight principles does not mean the AMA necessarily backs every idea on health reform that Obama has revealed so far. For instance, the president has called for creating a public health plan option linked with a national health insurance exchange to serve as competition for private plans. In its letter to the White House, the AMA says it supports a health insurance exchange to ensure coverage choice and portability, but it does not weigh in on the public plan option. To move toward universal coverage, Congress should build on the employer-based system and strengthen the safety net provided by publicly financed programs such as Medicare, Medicaid and the Children's Health Insurance Program, Dr. Nielsen and Dr. Rohack wrote.

Dr. Nielsen stressed that the organization is mindful of the need to watch the dollar signs as policymakers work toward the goal of universal coverage. "It's very important for us that all Americans have health care coverage that's affordable. But we do understand that we can't afford everything for everybody, so we need to have fiscally responsible conversations."

The letter proposes expanding on Obama's principles in a number of ways, including:

Reforming and improving the insurance market through the use of modified community rating, guaranteed renewability and fewer benefit mandates.
Assisting low-income individuals through premium subsidies and cost-sharing assistance.
Promoting medical home models to reduce system fragmentation and improve care coordination.
Establishing antitrust reforms that would allow groups of physicians to contract jointly with payers as long as the doctors certify they are collaborating on health information technology and quality improvement initiatives.
Easing the effect of liability pressure on the practice of defensive medicine through innovative approaches, such as health courts, early disclosure and compensation programs, and expert witness qualification standards.

Some signs of progress

Dr. Nielsen said she is encouraged by the progress already made in talks about Medicare physician payment reform, a key part of the AMA's broader health system reform agenda. Physicians soon may begin to see pilot programs testing various payment models in an attempt to find long-term alternatives to the current system, she said. "It's early, but there's no question that's on the table."

In his fiscal 2010 budget proposal, Obama said Medicare's physician pay cuts as mandated by law are not practical. He said Congress should plan on spending $330 billion over the next decade to repeal the current pay system instead of simply patching it year after year.

The next steps on the issue are up to lawmakers. The AMA was one of more than 70 medical organizations that signed an April 13 letter to the House Budget Committee asking Congress to retain a section in the House budget proposal that could make it easier for lawmakers to approve a payment overhaul. By suspending "pay as you go" rules for a large initial portion of a physician pay proposal, the House budget would obviate the need to find hundreds of billions of dollars in offsets otherwise needed to prevent the overhaul from running up deficit spending. At this article's deadline, lawmakers were still negotiating over the differences between the House budget blueprint and the Senate version, which does not include the pay-go exemption.

At least two key Senate leaders think Congress can move quickly, even though it is contemplating the largest health system overhaul proposed in 15 years. "We have jointly laid out an aggressive schedule to accomplish our goal" of enacting comprehensive health system reform, said an April 20 letter to Obama from Senate Finance Committee Chair Max Baucus (D, Mont.) and Senate Health, Education, Labor and Pensions Committee Chair Edward Kennedy (D, Mass.). Both committees plan to mark up legislation in early June.

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ADDITIONAL INFORMATION:

Obama's 8 principles

The American Medical Association has aligned itself with President Obama's eight basic health system reform principles and provided ideas about how Congress and the administration can achieve them. Here are the original principles for a reform plan as the White House describes them:

Guarantee choice: The plan should provide Americans a choice of health plans and physicians. People will be allowed to keep their own doctor and their employer-based health plan.

Make health coverage affordable: The plan must reduce waste and fraud, high administrative costs, unnecessary tests and services, and other inefficiencies that drive up costs with no added health benefits.

Protect families' financial health: The plan must reduce the growing premiums and other costs American citizens and businesses pay for health care. People must be protected from bankruptcy due to catastrophic illness.

Invest in prevention and wellness: The plan must invest in public health measures proven to reduce cost drivers in our system -- such as obesity, sedentary lifestyles and smoking -- as well as guarantee access to proven preventive treatments.

Provide portability of coverage: People should not be locked into their jobs just to secure health coverage, and no American should be denied coverage because of preexisting conditions.

Aim for universality: The plan must put the United States on a clear path to cover all Americans.

Improve patient safety and quality care: The plan must ensure the implementation of proven patient safety measures and provide incentives for changes in the delivery system to reduce unnecessary variability in patient care. It must support the widespread use of health information technology with rigorous privacy protections and the development of data on the effectiveness of medical interventions to improve the quality of care delivered.

Maintain long-term fiscal sustainability: The plan must pay for itself by reducing the level of cost growth, improving productivity and dedicating additional sources of revenue.

Source: The White House, AMA letter (www.ama-assn.org/ama/pub/news-events/news-events/obama-principles-health-care.shtml)

DeParle weighs in on health system reform

With the expectation of an eventful year ahead on health system reform, the new leader of the reform effort within the White House started working more than a month before her new office was officially created.

Nancy-Ann DeParle, the first head of the newly minted White House Office for Health Reform, said during an April 15 briefing with reporters in Washington, D.C., hosted by the Kaiser Family Foundation, that she has been plugging away since her appointment was announced March 2. Obama created the new office by executive order on April 8.

Most of her time has been spent meeting with various lawmakers and their staffs on the reform issue, DeParle said. But she reported that she also met with the American Medical Association, the American Hospital Assn. and "various groups who I have reached out to or who have reached out to me to talk about how we get this done this year."

The efforts have already borne fruit, DeParle said. Meetings with state leadership in rural areas of the country, for instance, have highlighted the need for policymakers to help small business owners and their workers, many of whom have been denied coverage or have seen steep increases in their premiums because of preexisting conditions.

"The stories are heartbreaking, and I think they're the reason why this president ... has made it clear that health reform must not wait, cannot wait and will not wait another year."

DeParle took reporters' questions, including several on Obama's plan to save $180 billion over 10 years by requiring private Medicare plans to bid competitively for contracts, with the federal government paying the average of all bids. Confronting payment disparities between Medicare Advantage and the traditional fee-for-service program allows the White House to set the stage for broader Medicare payment reforms, she said.

"Everyone acknowledges that the Medicare Advantage plans, particularly the private fee-for-service plans, nationwide have been paid something like a 12% to 14% premium above what traditional fee-for-service Medicare has been paid to provide the same services," DeParle said.

DeParle also discussed plans to promote the medical home model in an effort to reduce system fragmentation, comparative effectiveness research to determine the best treatments and incentives to help address the growing shortage of primary care physicians.

Friday, May 8, 2009

Promising New Malaria Vaccine Is Extracted From Irradiated Mosquito Spit

The U.S. Food and Drug Administration has approved human trials of a new malaria vaccine: it is made from a weakened form of the entire malaria-causing parasite, Plasmodium falciparum, extracted from irradiated mosquito spit. Sanaria, the company producing the vaccine, has been working with a particular stage of the P. falciparum parasite called a sporozoite. This is the stage when it leaves the mosquito’s salivary glands to enter the human bloodstream [Reuters].

To produce the vaccine, Sanaria weakens the parasite by feeding human, infected blood to mosquitoes, then [exposes] the mosquitoes to enough irradiation to cripple the parasite [New Scientist]. The mosquitoes are then killed and their saliva is extracted by hand, with each of six laboratory workers averaging a rate of 100 mosquitoes per hour. With every mosquito containing about two doses in its spit, Sanaria founder Stephen Hoffman estimates that about 1,200 doses are produced per hour.

The vaccine uses a model similar to others that prevent diseases like measles and polio, in which weakened bacteria is injected, creating an immune response without causing illness. In the Sanaria vaccine, the body recognizes the malaria parasite as a foreign material [CNN], but it does not pose a threat of disease because the mosquito was irradiated. The theory is that by exposing the body to something that looks exactly like the dangerous parasite but is actually harmless, the body’s immune system will develop much stronger resistance than if it encounters vaccines based only on tiny elements of the parasite. In earlier trials of the spit vaccine, before the manufacturing process was perfected, recipients received virtually full protection against malaria for at least 42 months [New Scientist]. That’s an improvement on another vaccine being tested by GlaxoSmithKline, which was based on a fragment of the parasite; that vaccine has been shown to reduce infections in children by about 50 percent.

Starting in May, the vaccine will be tested on volunteers in Maryland. They will receive the vaccine and will then sit in booths filled with malaria-infected mosquitoes until they’re bitten and infected. Researchers believe the vaccine will protect the volunteers, but if any do come down with malaria researchers say they can be treated easily and safely. If these trials are successful, researchers will initiate trials on adults in Africa, and then children [CNN].

Thursday, May 7, 2009

Alzheimer's 'is brain diabetes'

The most common form of dementia may be closely related to another common

disease of old-age - type II diabetes, say scientists.

Treating Alzheimer's with the hormone insulin, or with drugs to boost its effect, may help patients, they claim.

The journal Proceedings of the National Academ

y of Sciences reports insulin could protect against damage to brain cells key to memory.

UK experts said the find could be the basis of new drug treatments.

The most exciting implications are that some diabetes drugs have the potential to be developed as Alzheimer's treatments

Spokesman, Alzheimer's Research Trust

The relationship between insulin

and brain disease has been under scrutiny since doctors found evidence that the hormone was active there.

The latest study, joint research betw

een Northwestern University in the US and the University of Rio de Janeiro in Brazil, looked at the effects of insulin on proteins called ADDLs, which build up in the brains of Alzheimer's patients and cause damage

They took neurons - brain cells - from the hippocampus, a part of the brain with a pivotal role in memory formation.

These were treated with insulin and a drug called rosiglitazone, given to type II diabetics to increase the effect of the hormone on cells.

After this, the cells were far less susceptible to damage when exposed t

o ADDLs, suggesting that insulin was capable of blocking their effects.

Treatment hope

Professor William Klein, from Northwestern, said that drugs to boost the brain's sensitivity to insulin could

provide "new avenues" for treating Alzheimer's disease.

"Sensitivity to insulin can decline with aging, which presents a novel risk factor for Alzheimer's disease - our results demons

trate that bolstering insulin signalling can protect neurons from harm."

His colleague, Professor Sergio Ferreira, from Rio de Janeiro, said: "Recognising that Alzheimer's disease is a type of brain di

abetes points the way to novel discoveries that may finally result in disease-modifying treatments for this devastating disease."

A spokesman for the Alzheimer's Research Trust said that the study shed light on how insulin i

nteracted with toxic proteins linked to the disease.

"People with diabetes are at higher risk of developing Alzheimer's. It is well known that insulin affects how the brain works, and this research adds more evidence to the possibility that

Alzheimer's could be a type of brain diabetes.

"The most exciting implications are that some diabetes drugs have the potential to be developed as Alzheimer's treat

ments."

Dr Victoria King, of the charity Diabetes UK, said: "We already know that people with Type 2 diabetes are at a higher risk of developing Alzheimer's disease.

"This study is in its early stages but it is

interesting because it suggests that insulin, alongside drugs that help the body use insulin more effectively, may protect against the underlying biological mechanisms associated with

the development of Alzheimer's disease.

"This is very intriguing and could potentially help with new treatments for Alzheimer's disease and shed further light on its links with diabetes. We

would certainly welcome more research in this area."

Wednesday, May 6, 2009

As Swine Flu Spreads, Focus Shifts to a Potential Vaccine

As the swine flu outbreak continues to spread, with Russia, South Korea, and Australia joining the list of countries with suspected cases and the death toll climbing in Mexico, attention has turned to the potential of a swine flu vaccine that could protect populations from infection. But a new vaccine takes some months to develop. Says Iain Stephenson, an expert on flu vaccines: “We are in a position where if a swine flu virus becomes a pandemic we don’t currently have a vaccine for it…. I think that it is unlikely there will be widespread vaccine in less than six to eight months” [Telegraph]. In the meantime, says Stephenson, patients can be treated with antiviral drugs.

International health officials haven’t yet decided whether the swine flu poses a serious worldwide threat that would call for the immediate prioritizing of a vaccine. The pharmaceutical company Novartis said it had received the genetic code of the new virus strain, enabling it to start work on evaluating production, and it hoped to receive the actual virus in its laboratories “in the near future.” … But the World Health Organisation (WHO) said it would only call for large-scale production of such a pandemic vaccine if it strongly believed the world was on the edge of an unstoppable global outbreak of flu [Reuters]. Vaccine companies are currently producing the seasonal flu vaccine, and health officials worry that calling them off that task could lead to shortages of the common flu shot.

If drug companies are given the green light to start production of the new vaccine, most will use a traditional method called the attenuated method, in which scientists grow the new strain of virus in chicken eggs. The virus is then killed to make it safe. Upon injection, the dead virus acts as an antigen that trains the immune system to recognize the virus, so that a real infection would trigger an immediate immune response. But even though vaccine is more efficiently produced than in the past, say WHO officials, some infectious-disease experts say eggs can be unreliable. “They can go bad, the strain might not grow fast enough, or at all” [USA Today], says vaccine expert Brian Currie. Growing the virus is cell cultures is a slightly faster process, although some experts argue that both egg and cell culture approaches are outdated.

If the swine flu spreads rapidly, the government may turn to companies whose experimental technologies promise to yield large batches of vaccines more quickly. [Start-up company] Vaxart makes vaccines by combining an antigen – in this case, the swine-flu DNA – with a non-replicating viral vector and an adjuvant that boosts the immune response. This “modular” approach is about two months faster than egg or cell-culture systems, said Chief Executive Mark Backer. If swine flu becomes a large problem, U.S. regulators may permit Vaxart and others to move rapidly from animal research to human studies, he said [The Wall Street Journal].

Monday, May 4, 2009

Volunteers and the Great Unknown: Interview with Clinical-Trial Participants

Amanda Redig

Don’t think, try.
—William Harvey, physician (1578-1657)

In one of the earliest recorded clinical trials, British physician Edward Jenner decided to test his theory that infection with the cowpox virus provided protection from the more deadly scourge of smallpox. Jenner’s approach, however, is also a bioethicist’s worst nightmare. In the waning days of the 18th century, there was no such thing as informed consent, institutional review boards, or human-subjects protection. So, without much fanfare, Jenner simply transferred pus from a cowpox pustule to an incision he created on the arm of his 8-year-old test subject, James Phipps, and subsequently exposed the boy to smallpox. Luckily for Phipps, Jenner’s idea did not prove fatal: cowpox exposure did offer smallpox protection. When the Royal Society of London declined to publish his findings, Jenner simply turned to more pediatric subjects to prove his point. As legend has it, this included his own infant son [1].

LEARNING OBJECTIVELearn from first-person reports why individuals—both healthy and ill—agree to participate in human-subjects research.

In the end, Jenner’s ideas—if not his methods—were not as far-fetched as first imagined. While his discoveries were responsible for the first smallpox vaccine and earned him a place in medical history as the father of immunology, much has changed in the way physicians interact with patient research subjects since Jenner’s time. After the trials at Nuremberg and the Declaration of Helsinki, the rights and protection of the patient-subject are at the forefront of any modern research trial [2].

What motivates people to participate in research protocols today? Entire departments and layers upon layers of federally mandated paperwork exist to protect both the scientific integrity of research as well as the health and well-being of human test subjects. One fundamental detail, however, has not changed in the days since Jenner exposed neighborhood children to smallpox: clinical research must necessarily contain an element of the unknown. Yet people still participate.

I decided to interview some clinical-study participants to see what they had to say about their decision to participate in a study and whether or not they would do so again. The studies represented were a trial that compared a new cancer drug to existing therapy and two preclinical research studies in which normal (non-sick) volunteers underwent neurological imaging or donated bone marrow for laboratory studies. Given the diversity of study aims, the answers of study participants may surprise you. And in a way, their thoughts about participating in clinical-research projects embody the same spirit of inquiry that first set Jenner on his way over 200 years ago.

In their own words. “Why would anyone want to do that?” This is one of the first questions that comes to mind when one considers the uncharted waters of a clinical protocol. Yet as those close to patient-subjects make clear, sometimes it is the promise of something new and different that makes a study appealing. “My mom participated in the study because we were out of options at that point,” a family member said, referring to a study that was designed to test the efficacy of a new medication to treat a particular kind of cancer.

The drug she had been taking…stopped working, and the side effects of interferon were nearly killing her. We heard about Gleevec and weren’t sure she would qualify for the clinical trial…but we thought, if she qualified, then why not? We had nothing to lose. She wasn’t paid, but the promise of a new drug gave us hope when we were already expecting the worst.

This particular patient-participant’s disease was so advanced at the time of therapy initiation that she eventually succumbed to it. The drug she received, however, is now standard therapy for this type of leukemia (chronic myelogenous leukemia) and has had a profound influence on pharmaceutical drug design. “Ultimately my mom knew she was fighting a losing battle,” her daughter noted. But, “I think she would have done it again, especially to be on the trial for a drug that revolutionized the therapy of CML as we know it.”

The same thread of hope is also a part of the motivation for a normal volunteer who participated in a different study that involved donating bone marrow for laboratory research. “If I truly believe in the utility and promise of clinical studies,” he said, “then I feel obligated to participate in whatever way I can to further the research goals of others, even if it means enduring slight discomfort.” This thought is echoed by a participant in the same trial who, even though she initially thought the bone-marrow-donation process was too painful to consider doing again, decided the right trial might change her mind. “Well, actually maybe I would do it again if it was something to help children or a disease like cancer or MS,” she said. “Clinical research is a wonderful thing, and it should be funded more,” she said.

Financial reward. The promise of hope is indeed a powerful motivation. Yet the question of financial remuneration is also powerful and one of the most complex issues involved in clinical studies. To avoid coercion, money offered to participants cannot be deemed excessive. Yet, particularly for the non-sick volunteers needed to serve as healthy controls for many types of studies, shouldn’t there be some payback for donation of time and the experience of undergoing unpleasant and often painful procedures? Who is to say how much is enough (or too much)? And does money of any kind make people more likely to participate? The answer appears to be more convoluted than one might imagine. As one participant stated,

I donated bone marrow for a friend’s PhD research project. The money was nice (I was paid $150), but I mostly donated because I liked the idea of being included in my friend’s project. As a future physician, I wanted to know what it was like to donate bone marrow, so I would understand what patients experience during bone-marrow biopsies.

This thought was echoed by another participant in the same study who remarked,

While I was compensated for my time and discomfort, this was not the primary motivation for participation. Knowing that part of me might be used to help better understand disease and perhaps lead to an improved diagnostic method or therapy was rewarding enough.

A third participant who also donated bone marrow concurred. “Well, for the money, yes,” she said, when asked why she participated. “But also for the science factor. Depending on what it was for, I wouldn’t need to be paid to consider it.”

Sometimes, this same sense of curiosity leads people to participate in multiple studies. Another participant in the bone-marrow study remarked, “While a laboratory technician…I participated in several studies that involved transcranial magnetic stimulation (TMS) and MRIs. I was not compensated for the studies, but I participated because I was fascinated by the science and really interested in seeing the scans of my own brain.”

Would you do it again? Repeat participation in future studies is—of course—the best way to gauge a clinical subject’s overall experience on a research protocol. For the volunteers interviewed here who were not sick, the overwhelming answer seems to be affirmation of the promise of clinical research. As one participant put it,

I would definitely do it [donate bone marrow] again. Since then, I have donated blood for basic science research….The first time I did it, the guy unfortunately missed three veins and couldn’t get any blood. I would still go back. I love the idea that I can contribute to science.

Another volunteer on the bone-marrow protocol added, “I hope to continue in whatever way I can to help researchers pursue their studies.”

Yet participation in a clinical study of any kind is not an entirely benign experience. It is sometimes difficult to tell whether the new drugs and devices being tested are working. “She did start to feel better,” a family member noted about a cancer patient participating in a trial evaluating a new medication. “But the course of the illness…and her death were about the amount of time the doctor had predicted, regardless of the [drug].” Furthermore, the time commitment required for evaluation of new therapies can be exhausting for people who are already sick. As the daughter of one participant put it: “I think my mom was getting frustrated with the constant appointments.” Even for normal volunteers who participate in studies that do not involve long-term follow-up, there is still the upfront commitment of time, not to mention sometimes unpleasant procedures. “No, I wouldn’t do it again. It was too painful,” remarked a study participant in reference to a bone-marrow donation.

Much has changed since the early days of medical research, but what will never go away is the challenge of finding a way to pursue progress when that progress requires human experimentation. Participation in a clinical study of any kind is a significant commitment. Yet it seems that such studies will continue to move ahead thanks to the sense of purpose felt by patients and normal volunteers alike. This general optimism is perhaps best summarized by an individual who lost her mother to cancer: “…I knew the medicine probably wasn’t going to make a miracle happen, but at least the [experimental] drug gave us all something new to have hope and faith in. And even if [it] didn’t help my mom, we were at least playing a part in something that maybe would work for someone else’s mother. I am sure my mom would agree.”

References

BBC. Historic figures: Edward Jenner (1749-1823). http://www.bbc.co.uk/history/historic_figures/jenner_edward.shtml. Accessed February 24, 2009.
The World Medical Association. World Medical Association Declaration of Helsinki. 2008. http://www.wma.net/e/policy/b3.htm. Accessed February 24, 2009.

Amanda Redig is an MD/PhD student at Northwestern University’s Feinberg School of Medicine in Chicago. She will defend her doctoral thesis in April 2009 and graduate from medical school in May 2010, at which time she plans to pursue a career in academic hematology-oncology. As a research scientist, future physician, and prior patient-research subject, Ms. Redig is committed to clinical research that is medically exciting and ethically sound.

Politics of Participation: Walter Reed’s Yellow-Fever Experiments, April 2009

Enrollment of Economically Disadvantaged Participants in Clinical Research, January 2009

Helping Patients Decide whether to Participate in Clinical Trials, January 2007

Saturday, May 2, 2009

The New Theory About Why Animals Sleep: to Maintain the Immune System

Why do we sleep? An international team of researchers recently published evidence that slumber may have evolved to protect animals from dis ease. They examined sleep patterns of more than 30 mammalian species—including hedgehogs, baboons, seals, and elephants—along with the strength of their immune systems and levels of parasite infection. Some animals, such as giraffes, doze for just a few hours a day; others, such as armadillos, snooze for 20 hours.

The study found that animals that sleep the longest had six times as many immune cells as those that take short siestas. Additionally, critters catching the fewest z’s had 24 times as many parasites as the best-rested species. “Maintaining the immune system may be the reason sleep has evolved,” says lead researcher Brian Preston, an evolutionary ecologist at the Max Planck Institute for Evolutionary Anthropology in Germany.

Other scientists note that boosting the body’s defenses is just one of many vital functions of sleep. It also allows the brain to reorganize connections between neurons, consolidate memories, and synthesize proteins and cholesterols that are important in tissue repair, says Allan Pack, director of the University of Pennsylvania Center for Sleep.

Another new study bolsters the link between sleep and immune function in humans. Among 153 people voluntarily infected with a cold virus, those who averaged less than seven hours of sleep each night were nearly three times more likely to get sick than those with eight hours or more. “We’ve barely scratched the surface when it comes to understanding the health implications of sleep,” Preston says, “but it’s clear we should all get a good night’s rest.”

Friday, May 1, 2009

eVoice® Alert

May 1, 2009

AMA Web site provides latest info on H1N1 flu (swine flu)

The Centers for Disease Control and Prevention (CDC) has confirmed that human cases of swine influenza A (H1N1) virus infection have been identified in 11 states and several countries. Investigations are ongoing to determine the source of infection and whether additional people have been infected with the virus.

The AMA Web site includes up-to-date clinical guidelines, resources and news to help physicians and the public disseminate the most recent information about swine flu infections. These guidelines, developed by the CDC, include the use of masks, respirators and antiviral medications; infection control; and case identification. The AMA continues to work with the CDC to monitor swine flu developments closely and will post additional resources on these developments as they become available.

If you would like to receive free, automatic e-mail updates from the CDC as new information becomes available, visit the CDC Web site to subscribe.

University of Louisville AMA-MSS

Saturday, May 9, 2009

AMA letter backs Obama's broad principles for health system reform